Basic Information
| Provider Information | |||||||||
| NPI: | 1790748531 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARNES | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2201 CENTRAL AVENUE | ||||||||
| Address2: | |||||||||
| City: | ST. PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337138844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138857766 | ||||||||
| FaxNumber: | 8138890167 | ||||||||
| Practice Location | |||||||||
| Address1: | 2201 CENTRAL AVENUE | ||||||||
| Address2: | |||||||||
| City: | ST. PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337138844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278711535 | ||||||||
| FaxNumber: | 7278247133 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2006 | ||||||||
| LastUpdateDate: | 02/24/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | PY3562 | FL | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 205047100 | 05 | FL | MEDICAID |